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communication failures 2(passive) caused bysentinel events
clinical communication gaps Knoxville , Tenn.(passive) caused bysentinel events
corrective actionsto preventreoccurrence of sentinel events
Guidelines and actionsto preventsentinel events
Improving Health Literacy to Protect Patient Safety 12 Goal Oriented The Joint Commission ’s National Patient Safety Goals were createdto preventsentinel events from occurring
solutions for clientscan preventsentinel events
Family Members Dimensions of Critical Care Nursing(passive) Caused bySentinel Events
poor communication Posted on October 7 , 2012 by Neil Versel LOS ANGELES(passive) caused bysentinel events
Findings that are determined process issues and new solutionsto preventsentinel events from occurring
poor communication Filed Under : health reform Legislation Patient Protection and Affordable Care Act patient safety politics quality Tags(passive) caused bysentinel events
a few high risk areascan triggersentinel events
Stepsto preventsentinel events
established the new system and action planto preventsentinel events
the sentinel events they helppreventsentinel events
Plansto PreventSentinel Events
Startegies nurses can useto preventsentinel events from occuring
Utilizing hospital event reporting systems ( ERS ) to document mislabeled blood samples and transfusion related adverse events will helppreventmistransfusion sentinel events
the early signs and symptoms of critical illnessescould createsentinel events
These locksets helppreventsentinel events
Medical alarms that are supposed to make nurses aware that something is wrong with the patient and preventhave resultedsentinel events
surveyors during the survey(passive) discovered bysentinel events
fatigue resulting from poor schedules(passive) caused bysentinel events
Using hospital standardsto preventsentinel events
Perform time - out / Universal Protocolto preventsentinel events
to develop soundhospital systemsto preventsentinel events
medication errorsmay preventsentinel events
Three Quality Indicatorscan triggersentinel events
an obstetrician and a clinical nurse specialist(passive) created collaboratively byactual sentinel events
practical strategies ... helppreventsentinel events
A Systems Approach to Sentinel Events / JCAHO086688646X / 978 - 0866886468 /PreventingSentinel Events
Why Are We FailingTo PreventSentinel Events
All efforts , including a focus on high - risk drugscausesentinel events
focused planto preventsentinel events
troublescausesentinel events
that they are doing everything possibleto preventsentinel events
the gaps mentioned in the PEJ article(passive) often caused bysentinel events
standardizing the procedure of immediate postnatal SSCto preventsentinel events
failures in communication(passive) caused bysentinel events
all nurses ... helppreventsentinel events
The NDT specialist ... helpingto preventsentinel events
to patient deathleadingto patient death
to patient injury or deathleadingto patient injury or death
serious injury or deathcausingserious injury or death
in death or serious injury to patientsresultingin death or serious injury to patients
serious harm or deathcausedserious harm or death
in severe harm or deathmay resultin severe harm or death
death or permanent disabilitycausingdeath or permanent disability
to a patient 's deathleadingto a patient 's death
in a death or severe loss of functionresultin a death or severe loss of function
in physical or psychological injury or deathresultin physical or psychological injury or death
in death ... permanent harm , or severe temporaryresultin death ... permanent harm , or severe temporary
in death.--In addition to the report required under paragraph ( 1resultingin death.--In addition to the report required under paragraph ( 1
in permanent harm or death from Jan. 1 , 2010resultingin permanent harm or death from Jan. 1 , 2010
in permanent patient harm or death between January 1 , 2010 , and June 20 , 2013resultedin permanent patient harm or death between January 1 , 2010 , and June 20 , 2013
in permanent patient harm or death from January 1 , 2010 ... to June 30 , 2013resultedin permanent patient harm or death from January 1 , 2010 ... to June 30 , 2013
in permanent disability or death from inadvertent intrathecal administration of vinca alkaloidsresultingin permanent disability or death from inadvertent intrathecal administration of vinca alkaloids
in death or serious physical or psychological injury to a patient and is not related to the natural course of the patientresultsin death or serious physical or psychological injury to a patient and is not related to the natural course of the patient
an in - depth root cause analysis to determine the cause of the event as well as potential solutionswill typically triggeran in - depth root cause analysis to determine the cause of the event as well as potential solutions
actionsparksaction
to recognize senior citizensdesignedto recognize senior citizens
to research in determining why errors were happening and how they can be preventedleadto research in determining why errors were happening and how they can be prevented
to global awareness of the rapidly evolving situationleadingto global awareness of the rapidly evolving situation
from this approachresultfrom this approach
in organizational processes and systemscausesin organizational processes and systems
an investigation ( M8:14triggeredan investigation ( M8:14
to poor outcomes due toleadingto poor outcomes due to
legislation(passive) being prompted bylegislation
environments that facilitate high - quality geriatric careCreateenvironments that facilitate high - quality geriatric care
to deathsledto deaths
in perinatal mortality or permanentresultingin perinatal mortality or permanent
from homebirth transfersresultingfrom homebirth transfers
Sentinel Events Caused by Family Members Dimensions of Critical Care NursingPreventingSentinel Events Caused by Family Members Dimensions of Critical Care Nursing
from communication breakdown – 65 % of the timecommonly resultsfrom communication breakdown – 65 % of the time
a significant acute disruption of maternal - fetal gas exchangemay causea significant acute disruption of maternal - fetal gas exchange
APHI injuries(passive) are usually caused byAPHI injuries
in unexpected occurrencesresultingin unexpected occurrences
from telemedicine Distant - site practitioner licensed in originating site sresultingfrom telemedicine Distant - site practitioner licensed in originating site s
in immediate and significant savingsresultingin immediate and significant savings
an investigation by state health department inspectorsshould have triggeredan investigation by state health department inspectors
to litigation by the Joint Commission on Accreditation of Healthcare Organizationleadingto litigation by the Joint Commission on Accreditation of Healthcare Organization